Medical Chart Audits in a Primary Care Setting

Audit – the very word brings visions of men in suits pouring over your records, looking for the slightest evidence of a mistake or wrongdoing.  However, not all audits are external or scary. Internal and self audits are in fact, a rather helpful tool to enhance both the profitability and efficiency of your work.

Handling hundreds of patients can be quite a chore.  To evaluate the efficiency of their performance, identify areas where improvement can be made and measure the quality of care provided; a chart audit is one of the best tools in a primary care’s arsenal.  Helping monitor and measure performance in areas like research, compliance, clinical and administration, a chart audit can serve many purposes.  Any and all aspects of a medical record can be audited through the use of this tool.

Quality improvement initiatives can be easily mapped and monitored through the use of chart audits.  For example, a practice might review charts to see how often a particular vaccine is offered, given or declined. If the audit determines that the vaccine is not being offered or given as recommended, then there is room for improvement.  The same practice could review the panels of individual physicians within the group to see if they differ in performance on this measure and to give focus to their improvement efforts.  Along with patient surveys, billings/claims data, discharge summary reviews, employee feedback and other similar data sources; chart audits are used for quality improvement efforts.

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Although there is no fixed linear process to a formal chart audit, there are typical steps that occur in setting one up.  The basic set up for a chart audit consists of:

  • Selecting a topic
  • Identify and define measurement parameters
  • Identify the target group / patient population
  • Determine sample size – it should be statistically valid for a chart review
  • Create simple audit tools that can be used by non-clinical staff too
  • Start collecting data based on your parameters of size and time
  • Summarize the results by collating the collected data
  • Analyze the collated data and compare the results against set benchmarks
  • Plan the next steps if required and put the plan into action

Chart audits can be useful tools in performance improvement and safety efforts.  However, it is essential to define what you want to measure and the criteria by which you will measure it.  Sample sizes can be chosen informally or determined in a statistically valid fashion – remember that too small will not provide enough data and too large a sample size can be overwhelming.  Summarize your data keeping the parameters in focus – after all, you do not wish to lose focus on what you want out of the audit.  Analyze the data to find out problem areas if any, scope for improvement and other areas of concern.  Work out a plan to counter the problems and put the plan into action.  Regular chart audits will certainly make a positive difference to your work, practice and your patient’s welfare and care.


References

  1. Barbara H. Gregory, M. M. (2008, July). Eight Steps to a Chart Audit for Quality. Retrieved October 26, 2016, from http://www.aafp.org: http://www.aafp.org/fpm/2008/0700/pa3.html
  2. Chart Audits in Quality Improvement . (2016). Retrieved October 26, 2016, from http://www.patientsafetyed.duhs.duke.edu: http://patientsafetyed.duhs.duke.edu/module_b/quaility_improvement.html
  3. Improving Your Office Testing Process. (2016). Retrieved October 26, 2016, from http://www.ahrq.gov: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/office-testing-toolkit/officetesting-toolkit9.html
  4. Managing Data for Performance Improvement. (2016). Retrieved October 26, 2016, from http://www.hrsa.gov: http://www.hrsa.gov/quality/toolbox/methodology/performanceimprovement/part3.html

 

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